By William C. Peters
In November 2008, the Kilgore (TX) Fire Department replaced its 1986 110-foot, rear-mount, straight-stick aerial truck that was out of service because it failed a ladder test with a new 2008 95-foot, mid-mount, custom aerial platform apparatus. The career fire department operated from two stations on the day of the accident with approximately 10 members on duty each shift. The members of each of the three duty platoons received factory authorized training, including both classroom work and practical exercises in December.
After completing the factory training, each shift practiced and drilled with the apparatus as time permitted. Some members reported taking the unit out in front of the station and setting it up; other times, they went to the local football field and flowed water.
On Sunday, January 25, 2009, the members of B shift from both stations met at approximately 1300 hours at Stark Hall, an eight-story college dormitory building, to practice setting up and operating the new truck. They spotted and stabilized the truck, and a group of three members elevated the platform to the roof. There was a parapet approximately 24 inches high above the roof level. Members got out of the platform and onto the roof. A second group of four firefighters then repeated the same exercise.
When the third group of four approached the roof area, they encountered some difficulty positioning the platform. The aerial was at full extension and slowly rotated into position. The operator felt that the platform was too high above the roof to open the doors and attempted to lower the elevation. Several members reported hearing a scraping sound followed by a “bang” sound. In the platform, the operator said it dropped fairly rapidly and set down on the wall. All indications are that a lifting eye on the bottom front edge of the platform caught the inner edge of the parapet.
The operator in the platform made three attempts to raise the elevation, but the ladder did not move. Members at the turntable saw the ladder bow outward and attempted to shut off power to the tip. Suddenly the platform released, first rocking back away from the building then forward again toward the building, tossing the four men about. Both platform doors sprung open, and firefighters Kyle Perkins, age 45, and Cory Galloway, age 28, were ejected, falling approximately 83 feet to their deaths.
The unit involved is a 2008 custom fire apparatus with a 95-foot, mid-mounted, aerial ladder platform. The aerial device is constructed of welded aluminum alloy extrusions assembled in four sections.
The vehicle is stabilized by two sets of down jacks and one set of under-slung outriggers. All are hydraulically operated with an electronic automatic leveling system.
The aerial movements of raise/lower, extend/retract, and rotation are powered hydraulically with electric-over-hydraulic controls located both at the turntable and in the platform.
The platform payload is rated at 1,305 pounds without water in the system (1,000 for personnel and 305 for equipment) and 805 wet (500 for personnel and 305 for equipment).
The platform was constructed of welded aluminum extrusions and aluminum sheet with approximately 18 square feet of floor space. A 42-inch-high guard railing was around the perimeter. Two inward-opening, self-closing doors were at the two front corners of the platform, and a “Mansaver Aerial Bar” enclosed the rear ladder opening. Six fall-protection anchor points were in the platform: two in the front, two on the sides, and two in the rear.
NFPA STANDARDS COMPLIANCE
The National Fire Protection Association (NFPA) standard that governed the construction of the aerial apparatus in 2008 was NFPA 1901, Standard for Automotive Fire Apparatus, 2003 edition. After examining the apparatus, the National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation team, of which I was a part, determined that the following NFPA requirements dealing with the construction of the platform that are pertinent in this accident had been met:
126.96.36.199.1 “Minimum floor area in platform 14 square feet.”
188.8.131.52.2 “A continuous guard railing, a minimum of 42 inches high on all sides.”
184.108.40.206.2.1 “A minimum of two gates to provide access to the platform.”
220.127.116.11.2.2 “Each gate provided with a self-engaging latch.”
18.104.22.168.2.3 “Inward-opening, self-closing gates or doors for access to and from the platform permitted to meet the continuous railing requirement.”
22.214.171.124.1 “Provisions shall be made so that personnel working on the platform can attach fall protection harness.”
The following NFPA requirements dealing with the apparatus and equipment that are pertinent in this accident had not been met:
126.96.36.199 “The equipment listed in 8.8.2 and 8.8.3 shall be available on the aerial fire apparatus before the apparatus is placed in service.”
188.8.131.52 “Aerial fire apparatus shall be equipped with at least the following equipment:
It should be noted that Texas fire departments are covered by the Texas Commission on Standards and Education, which publishes standards to be followed by fire departments operating in the state. The state fire commission has adopted some, but not all, NFPA standards pertaining to firefighting operations, equipment, and programs.
We determined the following chain of events through several eyewitness accounts, police witness affidavits, an examination of the apparatus involved, and a recreation of the accident scene.
The unit involved in the accident was a new, 95-foot, mid-mount, aerial platform apparatus. The platform was located at the fire department’s Central Station.
In December, factory authorized training was conducted by the same individual three times, once for each shift. Each session was approximately eight hours long and involved a PowerPoint® presentation in the classroom and practical exercises setting up and operating the apparatus from both the turntable and the platform. All personnel who were interviewed (except one) took the training. The manufacturer provided a generic operator’s manual. Some members reported that the training was interrupted by responses to fire and medical calls.
Continuing training on the truck appeared to be left up to each individual shift. On at least one occasion, members took the truck to a local football field and performed elevated stream practice. The operator on the day of the accident received the factory training but was then off duty for several weeks on personal injury leave. He returned mid-January and recalled that the second time he operated the truck was outside the Central Station. This was the only practice he had until the day of the accident.
During the various training sessions, all members reported that the electric-over-hydraulic controls were very sensitive and required practice to get used to operating them. The controls at both the turntable and platform are essentially electric switches that, when operated, signal the valves that direct hydraulic fluid to the elevation and extension pistons and the rotational motor. A built-in delay is provided to eliminate the shock load that would be produced if the hydraulic valves were signaled fully open and fully closed suddenly. Some members had difficulty mastering the sensitivity of the controls, resulting in jerky movements.
Three days before the accident, B shift members were receiving training in an unrelated subject by the operations deputy chief when they were informed that they should be practicing more with the new truck. That same night, the unit responded to a structure fire at a local restaurant and operated the aerial master stream.
The two B shift captains discussed conducting training at Stark Hall, an eight-story dormitory building at a local college campus, on their next scheduled tour of duty, as it would be a Sunday and it was likely that there would be little activity around the college. This particular building was the tallest in their jurisdiction, and it would be the most challenging to reach the roof and operate on it if the building were involved in fire.
On Sunday, January 25, at approximately 1300 hours, members from the Central Station met members of Station 3 to conduct a joint exercise at the college. They spotted the apparatus in front of the high-rise dormitory building and operated the automatic stabilization system. There was some discussion as to the action of the indicator lights, but everything appeared to be in order. In addition to positioning the platform at several windows, the target was to reach the roof of the building in case the firefighters needed to perform a rescue or ventilation from that location. Prior to the department’s purchasing the truck, sales personnel demonstrated it at the same building to prove that it was capable of reaching the roof (photo 1).
|(1) Stark Hall at Kilgore College, with the tower set up as it was on the day of the accident. (Photos by author.)|
The first group of three personnel mounted the platform while it was still bedded. They went to the roof, where the platform was placed just above the parapet in a cantilever position. The three members got out of the platform and walked around the roof. They then took it back down and bedded it on the truck.
The second group, with four members, repeated the procedure. They kept the platform off the parapet, exited, and walked around the roof. When they brought the platform down, they tried to set it on the ground on the building side but found that there was not enough room. They then rotated the platform 180° and positioned it just off the ground on the right side of the truck in a parking lot.
Then the remaining four members entered the platform. One member was standing at the center operating control panel. A firefighter was standing on either side of him at the platform doors, and the fourth man was to the right rear of the platform.
The operator in the platform elevated the aerial device and rotated it toward the building. He attempted to see if he could perform more than one function simultaneously and found that he could not. He was informed by intercom from the ground that he was at full extension, and he slowly rotated the platform completely over the building. When it was centered, he indicated that it was too high above the roof to let the members out, so he tried to lower the platform toward the parapet. As he was trying to lower the platform, it dropped rather suddenly.
One member on the ground heard the engine idle up and observed the jacks on the driver’s side (closest to the building) raise off the ground (photo 2). Other witnesses at the turntable and in the platform reported hearing a “scraping” noise that sounded like “metal grinding on concrete”; some said it was followed by a “bang.” One member at the base of the ladder observed that they were “sitting on the building.” On examination, scrape marks were evident on the heavy aluminum lifting eye mounted under the platform on the left (passenger) side, and police detectives recovered aluminum fragments on the parapet. The marks were on the bottom and on the back side, suggesting that the lifting eye may have scraped along, then dropped, over the parapet (photo 3).
|(2) The outrigger on the driver’s side with the tower set up.|
|(3) Scrape marks are evident on the bottom and rear surfaces of the lifting eye.|
In the platform, the operator told the other members to “stay where they were at.” He then attempted to raise the elevation, but the platform would not move. Thinking it was the inherent control delay, he tried to raise the elevation again, without results.
One member at the base of the ladder observed the ladder starting to bow out and twist. In an interview, he indicated that the middle of the ladder was bowed up and the right side (looking up) was twisting up more than the left. He told the firefighter standing at the turntable control pedestal to shut the power to the tip off. When he looked up, the ladder was bowed even more. He then tried to reach across and turn the platform controls off. The conditions described are consistent with having the left lifting eye hooked on the building’s parapet and the elevating cylinders pressed up under the ladder attempting to raise it.
On the operator’s third attempt to raise the ladder, part of the concrete wall suddenly broke and the ladder sprung away from the building in a violent movement. The gouge mark in the rear edge of the parapet, as well as the pieces of concrete found on the top of the wall after the accident, support this sequence of events (photo 4).
|(4) A gouge mark and loose cement were found where the lifting eye contacted the parapet.|
The operator had been leaning out over the control panel to see what was holding them and was nearly ejected. He locked his knee under the control panel to stop his movement out over the top. His uniform baseball cap landed on the roof of the building. At the moment of release, all members were thrown toward the front of the platform. When the truck reached the end of the first oscillation, all members were thrown to the back of the platform. The operator hit the “Mansaver Bar” that secured the opening to the aerial ladder and bent the mounting two to three inches off-center (photo 5).
|(5) The “Mansaver Bar” that closed the rear of the platform was struck by one of the firefighters in the platform. The bar held, but the surface extrusion that it was mounted to bent.|
The truck then pitched forward again toward the building, catapulting the firefighters toward the front. The operator slammed up against the control panel, striking his pelvis. He was looking to the right and saw the first firefighter ejected out of the right door and almost immediately after caught a glimpse of the second firefighter exiting the open left door. The firefighter who was originally near the rear of the platform struck the front of the platform, injuring his sternum, and was on the floor looking out the open right door. It appears that he hit the intercom speaker, which was noticeably deformed (photo 6). The operator then pulled him back into the platform. When the truck came to rest, personnel in the platform and on the ground estimated that the platform was approximately 10 to 15 feet away from the building (photo 7).
|(6) The aerial intercom speaker mounted to the front of the platform was struck and deformed.|
|(7) After the platform sprang away from the building and stopped oscillating, it was estimated to be 10 to 15 feet away from the building.|
Emergency medical services were requested, and lifesaving procedures were initiated on the two fallen firefighters, without success. The two members remaining in the platform were unaware of what actually happened and why and, fearing an equipment malfunction, were lowered to the ground by a member operating the controls from the turntable. Both were injured and treated at a local hospital.
The crew was relieved of duty and returned to the station. A critical incident stress debriefing was conducted with the survivors.
Police detectives secured the scene and photographed and gathered evidence. The exact locations of the truck’s wheels, outriggers, jacks, and corners were marked with spray paint, which aided in recreating the scenario. Interviews were conducted with each person on the scene, and sworn witness affidavits were completed.
Three horrified students also witnessed the accident. Their statements were consistent in that they said that the truck was “rocking” and it “tilted” or “jerked” as the members fell to the ground.
Three distinct areas of concern contributed to this accident: operations, engineering, and safety precautions. If any one item in this chain of events had been altered on the day of the accident, I believe it would have been prevented.
The training program. As noted above, after the apparatus was delivered, a factory representative conducted a seven- to eight-hour training program that involved classroom work and hands-on training. Some members reported that the training was interrupted by response to fire and EMS calls.
The ongoing, in-service training varied. Some members reported that they operated the controls “a few times.” Others said that they practiced “quite often.” After the factory training was complete, a structured program of training should have been established and followed.
Familiarity with electric-over-hydraulic controls. The previous aerial apparatus most likely had direct hydraulic controls—the lever that the firefighter operates for each function is connected by linkage rods that open and close hydraulic valves directly. This type of system provides more “feel” for the operator; it is easier to “feather” the controls. It is impossible to provide direct hydraulic controls from a platform, so manufacturers have gone to electric-over-hydraulic controls, where electric switching opens and closes remotely mounted hydraulic valves. To prevent undue load shocks on the aerial device from suddenly opening and closing the hydraulic valves, a ramping delay is built into the control system.
This type of control requires consistent practice in using a “light touch” to get the aerial device moving before applying full pressure. Almost all members (except one who had experience in this type of control) commented on how “touchy” and “jerky” the controls were and how the delay required getting used to. During one of the evolutions, a member turned the platform controls over to another, more experienced operator when they approached the parapet because he feared striking the building with the platform.
On the day of the accident, the operator in the platform had only operated the controls on two previous occasions—once when the factory training was conducted and once on his own initiative when he returned from injury leave. Even though he had experience operating hydraulic equipment, he was still getting used to the electronic controls. It is understandable that he continued to raise the elevation control without movement, thinking that it was the built-in delay they were experiencing, when in actuality the platform was hooked on the parapet. The results were catastrophic.
Location. When it was decided that training on the new truck would be conducted during the previous tour of duty, a decision was made to practice at the eight-story college dormitory building. This was the tallest structure in the city and would present the greatest challenge in case of a fire (photo 8). The fire department knew that the platform could reach the roof line of the building, since it was demonstrated at that location before the city bought the unit.
|(8) Stark Hall was the tallest structure in the city and would pre-sent the greatest challenge in case of a fire.|
Although it is understood that firefighters must practice under realistic conditions, several members were having difficulty adjusting to the touchy controls. A less hazardous location with fewer obstacles might have been a better choice.
After the accident when the platform was being examined, it was observed that both platform doors were swinging out and were wide open. On closer examination, it was determined that the doorstops were bent and the doors had sprung out past the front control panel upright extrusions that provided the striker side of the door frame (photo 9). The stops that are supposed to prevent the door from opening outward are made of aluminum and measure approximately 81⁄2 inches long with approximately 11⁄2 inches of contact area. They are welded to the frame of the platform doors approximately 11⁄2 inches down from the top and stop just above the paddle latch inside the door.
|(9) The doorstops bent, and the doors were forced past the front control panel upright extrusions that provided the striker side of the door frame.|
The two firefighters who were ejected were thrown violently against the platform doors; it is obvious that the doorstops bent, allowing the doors to open. There are no test requirements in NFPA 1901, Standard for Automotive Fire Apparatus, that identify the amount of force these doors must withstand. Given the deformity of the stops and the results of this accident, it is obvious that they were not substantial enough to prevent this type of accident.
During the interviews, two firefighters indicated that they were concerned with the platform doors during training. In one police affidavit, a member stated that the doors could “spring out if you put any weight behind them.” Both said that if you pressed up against the bottom of the door with your leg, the door would stretch open several inches.
A more substantial doorstop should be developed and provided. Some suggestions are a longer stop, running from the top to the bottom of the door; thicker aluminum; or a wider stop to increase the contact area. The modified door should be type-tested to contain an impact load that is likely if an unbelted firefighter hits it.
Located at the rear of the platform, a “Mansaver Aerial Bar” secures the open access to the aerial ladder. During the accident, this bar was struck violently by one of the firefighters in the platform, and although the mounting point bent slightly, the bar did not fail. The component manufacturer stated that when it was developed, it was tested to 732 pounds without failure.
Mounting of the control panel. The platform control panel is mounted horizontally across the top of two 11⁄2-inch-square aluminum extrusions that also serve as the striker side of the platform door frame. A gusset plate braces the uprights on the outside of the platform approximately 18 inches up from the floor. The remaining area above the brace is freestanding (photo 10).
|(10) The freestanding portion of the center platform structure was able to flex, possibly contributing to the doorstop’s ability to pass|
The firefighter who struck the control console may have flexed the panel forward, which could have helped allow the doorstops to pass more easily. When the inspecting team shook the control panel, there was approximately 1⁄4 to 1⁄2 inch of movement between it and the doorstop. This was not as violent a shock load as the panel probably received on the day of the accident. To substantiate this possibility, it was noted that although the doorstops were noticeably bent, they would not pass the uprights and allow the doors to swing to the inside of the platform as they had originally, indicating that some stretching of the clearance likely occurred.
Location and shape of lifting eyes. The heavy aluminum lifting eyes are rectangular in shape and are welded to the monitor plumbing directly under the front of the platform, protruding lower than the platform floor. In this situation, both the shape of the eye and its location contributed to the platform’s getting caught on the parapet (photo 11).
|(11) The rectangular shape of the lifting eye and its location contributed to the platform’s getting caught on the parapet.|
The lifting eyes would be less likely to get caught if they were located back farther under the platform where the rubber bumpers could prevent them from making contact with any fixed object. In addition, if the outside profile was more rounded, they would probably be less likely to get caught on a fixed object.
The use of safety belts. NFPA 1901 has two requirements in reference to this subject. First, it requires attachment points that fall protection harnesses can be attached to in the platform. Second, it requires that four ladder belts be available before the apparatus is placed in service.
Six fall protection anchor points were located in the platform by the manufacturer—two in the front, one on each side, and two in the rear (photo 12). It was the fire department’s responsibility to either purchase new ladder belts or transfer the belts from the apparatus that was being replaced. Finally, it is the firefighters’ responsibility to wear and attach the harnesses when operating in the platform when provided.
|(12) The manufacturer had installed six fall protection anchor points in the platform.|
Many firefighters are lulled into a false sense of security when operating in a platform with 42-inch-high sides. Unfortunately, when an unusual incident occurs, such as happened here, the value of the safety belts cannot be understated.
During interviews, participants unanimously told the investigating team that safety belts were not required or worn during the factory training session. This sets a bad precedent for all future platform training and operations. I believe that if all personnel wore safety belts in the platform, the outcome of this accident would have been far less serious. The generic manual provided discussed the use of safety belts several times, and the manufacturer stated that it was discussed in the classroom sessions.
RECOMMENDED PREVENTIVE MEASURES
When a new apparatus is delivered, the fire department should outline a structured training program for the apparatus so that all shifts receive the same training. A schedule requiring a specific period of time, with a specific purpose (such as stabilizer operation, monitor operation, control from the platform, and control from the turntable) should be established and followed for all shifts.
Complete standard operating guidelines (SOGs) for the safe and correct operation of the particular apparatus that was purchased should be produced, and all members who operate the apparatus should read and understand them.
All personnel should practice with the controls to become intimately familiar with the “feel” of the electric-over-hydraulic system. Members should take the truck out every shift and operate it.
When factory training is being conducted, members should be placed off-duty so they can maintain continuity and concentration.
Safety belts in several sizes should be provided and worn at all times when firefighters are operating or practicing in the platform. The fire department SOG should establish and reinforce this requirement.
Stronger platform door stops above and below the latch need to be provided. The platform door stops failed when the members were thrown against them with the violent whipping motion of the ladder. The manufacturer should ensure that the stops are substantial, run the full length of the door, and can withstand the impact load of a firefighter striking them under severe conditions.
Lifting eyes or any obstruction under the front of the platform can easily get caught on obstacles. They should either be located farther back near the ground bumpers or rounded so they produce less of a snag hazard.
Like most accidents, this was the culmination of a series of events, any one of which, if altered, could have prevented the accident. If a different location had been selected for the drill, it is likely that the accident would not have happened. If the lifting eyes were not located precisely where they were, there would not have been anything to catch on the building. If the truck was spotted six inches to either side, the perfect alignment of the lifting eye and the rear edge of the parapet would not have occurred. If the platform door stops were more substantial, the doors might have held, preventing the members from being ejected. And, finally, if all members in the platform had worn safety belts, the tragic results could have been avoided.
To the great credit of Kilgore Safety Director Ronnie Moore, a press conference was held to review the findings in the NIOSH Fire Fighter Fatality Investigation and to discuss the precautions that have since been taken in Kilgore to prevent a repeat of this unfortunate accident. The findings include the following:
- The safety belts that were on order have since been delivered, and an SOG that requires the firefighters to use the restraints has been implemented.
- Modifications have been made to the platform, including extending the platform doorstops the full length of each door and removing the lifting eyes that became caught in the accident.
- The manufacturer has been contacted to repeat the factory training on all shifts.
- The aerial will be third-party tested before anyone is allowed to use it.
In an article published in theTyler Morning Telegraph, Moore said, “Our hope is that out of this tragic accident we can make a positive … in other words, prevent this from happening to any other department across the United States.”
Any fire department operating an aerial device should heed these important safety precautions and learn from this tragic accident.
WILLIAM C. PETERS retired after 28 years with the Jersey City (NJ) Fire Department, having served the past 17 years as battalion chief/supervisor of apparatus. He served as a voting member of the NFPA 1901 apparatus committee for several years and is the author of the Fire Apparatus Purchasing Handbook, the apparatus chapters inThe Fire Chief’s Handbook, and numerous apparatus-related articles. He is a member of the Fire Engineering editorial advisory board and of the FDIC executive advisory board. Peters was on the NIOSH Fire Fighter Fatality Investigation team that investigated this accident.